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Peri-aortitis is a rare and severe complication of endovascular treatment.
Report
Two cases of peri-aortic inflammation are reported after receiving an abdominal endoprosthesis as treatment for abdominal aneurysm. Both patients were successfully treated with high doses of prednisone and the grafts were left in situ.
Discussion
High doses of prednisone may be the treatment of choice for post endovascular peri-aortitis.
Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively modern technique for which the complications and long term results are still being understood. Randomised trials have shown a lower mortality and lower perioperative complications in selected patients as compared to open surgery.
More evidence of superiority to open repair and cost effectiveness is still needed, especially long term results.
New problems with the endovascular technique are emerging including breaking of the attachment hooks, migration of the graft, incomplete exclusion of the aneurysm, graft tearing, perforation or folding, endo leaks, fistulae, late rupture, graft thrombosis and graft infection.
The need for secondary interventions after endovascular repair with conversion to open repair is associated with a worse outcome if the graft could not be preserved.
Need for secondary interventions after endovascular repair of abdominal aortic aneurysms. Intermediate-term follow up results of a European collaborative registry (EUROSTAR).
Peri-aortitis is a severe and rare complication of endovascular therapy.
Treatment options include operative replacement of the stent or non invasive medical therapy but there is no consensus. For this reason we reported our experience with the non invasive medical therapy of this complication.
Report
Patient 1 is a 60 year old male who received an endovascular prosthesis for an infra-renal AAA (Fig. 1). Pre-operative findings were unremarkable. Three years after this procedure he presented with severe abdominal pain radiating to the back, malaise and fever.
Fig. 1Pre-operative CT scan showing non inflammatory aneurysm.
Physical examination showed a perspiring man in pain with abdominal garding.
Laboratory test included a sedimentation rate of 102 mm/sec, C-reactive protein of 213 mg/l and creatinine of 132 μmol/l. CT-scan was performed to evaluate the abdominal aorta which showed a thickened aortic wall with peri-aortic oedema (Fig. 2). No other pathology was found. The diagnosis of peri-aortitis was made. Six blood cultures were taken to make sure no bacterial infection was causing these problems. The patient received high doses corticosteroids (see discussion) after which the symptoms resolved. A follow up CT scan showed improvement (Fig. 3). The patient recovered with preservation of his graft.
Fig. 2Peri-aortic oedema after endovascular treatment.
Patient 2 is 72 year old male who received an endovascular graft for an AAA (Fig. 4). Pre-operative findings were unremarkable. Three months after being discharged the patient developed back pain and fatigue.
Fig. 4Pre-operative CT scan showing non inflammatory aneurysm.
Laboratory test showed a sedimentation>120 mm/sec, a C-reactive protein of 132 mg/l and creatinine of 125 μmol/l. A CT scan showed an inflammatory reaction around the bifurcation of the aorta (Fig. 5). Blood cultures remained negative. A leukocyte scan was performed, which showed mild leukocyte accumulation at the location of the aorta bifurcation.
Fig. 5Peri-aortic oedema after endovascular treatment.
This patient was also diagnosed with peri-aortitis. After reasonably excluding infection this patient received high doses corticosteroids. The patient recovered in just two days (Fig. 6).
Fig. 6Status after steroid treatment shows reduction of oedema.
Corticosteroids were continued and the patient is still being followed as an outpatient.
Discussion
Peri-aortitis after placing of an endoprosthesis is a relatively unknown complication of this new procedure. Peri-aortitis is characterised by a chronic specific retro-peritoneal inflammation.
There are similarities with retroperitoneal fibrosis. Presenting symptoms are pain in the back, flanks and/or abdomen, malaise and weight loss. The urine flow can be obstructed.
Laboratory findings show increased sedimentation and other inflammatory proteins. The diagnosis can be made by ultrasound, but often a CT-scan or MRI is necessary.
Differential diagnoses include chronic inflammation from an intra-abdominal focus, surgical trauma, auto-immune response, drugs or malignancy (mainly lymphoma). If there is doubt about the diagnosis a biopsy can be informative.
In our cases we chose not to perform a biopsy. Some medications are associated with retroperitoneal fibrosis (methysergide, methyldopa, amphetamines, cocaine and B-blockers), but none so far with peri-aortitis.
It is not known what causes the inflammation, but we presume the graft can trigger an inflammatory response. Treatment should focus on suppressing the inflammation. Prednisone (40–60 mg/day) for 6 weeks, followed by 5–10 mg for 6 months to a year results in improvement of the symptoms in most cases of retroperitoneal fibrosis, inflammatory AAA and peri-aortitis.
Steroids have detrimental effects on the immune response which needs to be considered before treatment. Cases of urinal obstruction associated with peri-aortitis have been published for which a J-stent or nephrostomy or surgery may be necessary.
The role of tamoxifen in the treatment of peri-aortitis is unknown. In our cases, corticosteroids where used successfully without the use of tamoxifen.
In conclusion, two patients with peri-aortitis after endovascular AAA repair were successfully treated with non-invasive therapy consisting of high dose corticosteroids.
References
Prinsen M.
Verhoeven E.L.G.
Buth J.
Cuypers P.W.
Van Sambeek M.R.
Balm R.
et al.
DREAM trial group. A Randomised Trial Comparing Conventional and Endovascular Repair of Abdominal Aneurysms.
Need for secondary interventions after endovascular repair of abdominal aortic aneurysms. Intermediate-term follow up results of a European collaborative registry (EUROSTAR).
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